2015 Annual Research Forum

LIVING WITH CANCER

OUR RESEARCH, YOUR FUTURE

On Friday the 19th of June PCFA & Ovarian Cancer Australia co-hosted our annual interactive research forum at the Walter and Eliza Hall Institute for Medical Research (WEHI) in Melbourne. The day was brilliantly facilitated by comedian, writer & professional speaker Catherine Deveny.

As always, we hope the PCFA & Ovarian Cancer Australia - Living With Cancer Research Forum was an informative, compelling and enlightening event. We are grateful to the speakers for sharing their knowledge with us and to the audience members who shared their thoughts, their questions, their stories and experiences. We also want to thank all of the staff at WEHI who contributed so much to make the event a success.

Below are the results of the post-event survey:

98% of respondents rated the forum overall as excellent or very good.

75% of respondents rated the overall presentations as extremely useful or very useful.

86% of respondents rated the panel discussion with health professionals as extremely useful or very useful.

91% of respondents rated the faciliator as excellent or very good.

We look forward to hosting another event next year to keep everyone informed of promising progress in the fields of ovarian and prostate cancers, and to ensure continued engagement with those living with prostate or ovarian cancer, their families & carers, our supporters and the wider community.

Progress in Ovarian and Prostate Cancer Research

Associate Professor Gary Richardson, Associate Professor Clare Scott and Dr Ben Tran gave the audience an excellent overview of the therapeutic landscape for ovarian and prostate cancers. Progress is being made in several therapeutic areas including chemotherapy, targeted therapeutics and immunotherapy.

A/Prof Gary RichardsonA/Prof Clare ScottDr Ben Tran

Chemotherapy in Ovarian Cancer

Changes are being made in the way ovarian cancer chemotherapies are administered. Traditionally chemotherapy is given intravenously at regular intervals spaced out to enable recovery between doses (usually 3 weeks). However, tumours don’t grow at a constant rate; they have periods of rapid growth and slower growth. The former tends to take place earlier on; during this time the cancer is most sensitive to chemotherapy. Increasing the frequency of the dose to better target this phase can have a beneficial effect for patients. Previously this 'dose-dense' approach was limited by side effects, particularly damage to the immune system, but new treatments are helping to offset these effects. Dose-dense chemotherapy is being explored in ovarian cancer and is showing improvements in survival.

In addition, the administration of higher doses of chemotherapy directly into the abdominal cavity is being trialled as an alternative to intravenous administration. While this is not suitable for all ovarian cancer cases, it is demonstrating some survival improvements for a subset of women with advanced ovarian cancer.

Progress is also being made in the development of drugs that help women who have become resistant to platinum based chemotherapy. This includes a new drug called Vinorelbine, which is currently in clinical trials.

Chemotherapy and Androgen Deprivation in Prostate Cancer

Chemotherapy is not traditionally offered as an early stage treatment for prostate cancer. It is usually given much later, following initial treatment with surgery and/or radiation, and androgen deprivation therapy (ADT). ADT is a front line treatment for good reason. According to Dr Ben Tran the development and progression of prostate cancer is driven by a class of hormones called androgens, including testosterone. ADT deprives the tumour of these androgens, reducing the tumour burden. But eventually prostate cancer cells find a way to produce their own testosterone. This is the major reason most prostate cancers become resistant to ADT. New therapies that address this are becoming available. For example, the drug Abiraterone blocks the production of testosterone inside the cancer cell, and the drug Enzalutamide stops testosterone from interacting with its target in the cancer cell. These new treatments are currently offered after chemotherapy, but Dr Tran believes that this restriction could soon change, allowing for more clinical flexibility. Moreover, in some cases certain chemotherapies may soon be offered much earlier. Docetaxel is a very tolerable chemotherapy often given after resistance to ADT arises; recent research in patients diagnosed with metastatic disease indicates that giving docetaxel at the outset could provide a significant improvement in survival.

Other advancements are being made with treatments that slow down the spread of prostate cancer, particularly to bone, such as Alpharadin for advanced prostate cancer.

Genetic profiling and the rise of targeted therapeutics

Recent advances in genetic profiling technology now allow researchers to rapidly and accurately map the human genome, enabling identification of genetic mutations that can be targeted by drugs. Almost half of all high grade serous ovarian cancers have problems with DNA repair, said Assoc Professor Clare Scott; this primarily arises from faulty BRCA1 or BRCA2 genes. When DNA repair is compromised genetic errors accumulate, allowing cancer to develop more easily. But too many mutations can cause cancer cells to die. To survive, cancers with faulty BRCA genes depend on a backup DNA repair pathway, which itself relies heavily on a protein called PARP. Drugs that stop PARP from working have been shown to extend survival for women with ovarian cancer who carry faulty BRCA genes or mutations in other genes that affect DNA repair. PARP inhibitors are approved in the US and Europe but are still experimental in Australia. Australian women who carry BRCA mutations may be able to access the drugs via a global access program.

BRCA mutations also play a role in prostate cancer, though in a much smaller percentage of cases. The subset of men who carry faulty DNA repair genes may benefit from treatment with PARP inhibitors. This is still in the experimental stage.

Another promising area of targeted cancer treatments relate the way tumours access nutrients. Assoc Professor Richardson explained that like normal tissues, tumours need nutrients to survive so they grow blood vessels in a process called angiogenesis.

"If you can stop that,” said Assoc Professor Richardson, “the blood vessels shrivel up and die… then the cancer shrivels up."

According to Assoc Professor Scott, the ovary contains an abundance of biological molecules that promote angiogenesis, and drugs like Avastin are designed to block them. New research suggests that for women with higher risk disease, early treatment with Avastin can be of benefit. Combination therapies, such as pairing PARP inhibitors with anti-angiogenesis drugs can also extend survival.

Angiogenesis plays a role in prostate cancer, but the anti-angiogenesis drugs trialled thus far have not fared as well. New drugs are now being explored so it remains an area of avid interest.

Immunotherapy in Ovarian and Prostate Cancer

Tumours hide from the immune system by sending chemical signals to local immune cells that effectively say 'nothing wrong here, move along'. The recent discovery of critical molecules involved in this process is leading to new treatments that prompt the immune system to fight cancer. This includes a class of drugs that target a protein called PD-1. These drugs allow the immune system to 'see' and destroy cancer cells. They are showing promise in melanoma and lung cancer, and are in the experimental stage for both ovarian and prostate cancer.

Therapeutic vaccines are being developed to prime the immune system against tumour cells. The approach uses dendritic cells, immune cells that can teach other immune cells what to attack. The method involves collecting a patient’s dendritic cells, exposing them to proteins associated with the cancer, then administering the dendritic cells back to the patient. Vaccine approaches have had mixed results, but a therapy called Provenge has demonstrated improvements in survival and is approved in the US for the treatment of prostate cancer. Vaccine approaches are still in the experimental stage for ovarian cancer. Other immunotherapies are also in development for both prostate and ovarian cancers; it continues to be a very active area of research.

The above represents some of the major advances in treatments for prostate and ovarian cancers. Recent years have seen a dramatic increase in treatment options and improved knowledge of the underlying biology of these diseases. The aim is to be able to select treatments, their order, and their frequency to best suit the needs of an individual patient. The use of genetic screening to guide treatment decisions is constantly evolving. Currently only a limited number of genetic mutations identified in cancer can be targeted with existing treatments; but for the patients who carry these mutations, this of course makes a big difference. More research is needed to understand how many other genetic mutations drive prostate and ovarian cancers, enabling them to initiate, grow and spread. The more we know, the more we can develop and expand the therapeutic arsenal. As this knowledge improves alongside genetic screening technologies, this could translate to benefits for a wider range of cancer patients. It is clear that a substantial step is being made in the right direction, one that is already extending survival times and improving quality of life.

Coping with Uncertainty: How Mindfulness can impact on quality of life

Ms Jane Fletcher is a health psychologist and psycho-oncologist, and is Director of the Melbourne Psycho-Oncology Service. She specialises in helping men and women contend with the psychological impact of a cancer diagnosis. She spoke to the audience about how mindfulness can help people cope with the inherent uncertainty that a cancer diagnosis brings. It almost doesn’t matter what the prognosis is, she explained. There is always a sense of uncertainty, and with uncertainty, there is a sense of having lost control.

"As human beings we like certainty, so we create stories in our mind."

But these narratives can generate a great deal of anxiety and fear as we fixate heavily on the future. Moreover, it’s not only the fear of the person with the cancer diagnosis that can cause anxiety, but also the fear of the people close to that person. Managing your own fear, as well as the fear of loved ones, can be very stressful. It is also not uncommon for a person to experience grief about what they are going through, as well as anticipatory grief for what might happen. Processing all these emotions can be difficult and isolating.

This psychological response to a cancer diagnosis can have physiological effects. After all, it is part of our natural survival mechanism that a perceived threat produces a physical reaction, an explosion of chemicals that perpetuate anxiety. If left unchecked, this can culminate in chronic fear and depression. Pulling yourself back from this is not easy, but it is achievable.

Ms Fletcher pointed out that these psychological and physiological responses are adaptable, and that means we can do something about it. Accurate, quality information can reduce anxiety she explained. Another important psychological tool is mindfulness.

"Whatever your prognosis, your challenge is to stay focussed on what is happening to you now," said Ms Fletcher. "Mindfulness being rather than doing… it is the process of paying attention and being present."

You can practice mindfulness with increased awareness of what you are doing in any given moment, and by doing this in a non-judgmental way. Mindfulness meditation is not thinking about nothing. That's not possible. Instead, meditation is about allowing yourself to focus. That focus could be feeling your breath, senses, body, thoughts and emotions. It's about being curious and letting go of judgment. It's about saying 'I wonder what this is about for me.'

Practicing mindfulness has very real effects on the body and brain.

"We know when we scan people's brains and we look at people who meditate and people who don't and we see distinct differences."

We see changes in the frontal lobe where we process emotions. There is improved neuroplasticity in the hippocampus, which is important for memory and learning. There are also changes in the amygdala, the part of the brain that controls fear responses.

Exercises such as yoga or tai chi can promote mindfulness, and there are also a wide range of mindfulness activities that can be incorporated into everyday life. Ms Fletcher recommends that you simply focus on whatever you’re doing. If you're washing dishes, watch the bubbles. Next time you're folding your clothes washing, focus on that. Savour what you eat. Even just 20 to 30 seconds of quiet breathing is enough to focus attention. Daily practice is important to give mindfulness a chance to work, even if it's just 10 minutes a day. The Cancer Council has mindfulness and relaxation CDs available, many guided meditation podcasts can be found online, and mindfulness apps for smartphones are also available.

Finally, Ms Fletcher advocates thinking about what brings you meaning and joy. Indeed, joy and mindfulness go hand in hand because joy is very much about the present, and this, in turn, can help pull you back from fearful stories about what may or may not be. Take time to ask yourself: What are your favourite things? Who and what makes your heart sing? Write these things down, keep them with you and reflect on them often on your journey.

Pilates Benefits During and After Cancer Treatment

Ms Debbie Summers is a physiotherapist who works closely with people undergoing cancer treatment, and particularly specialises in the rehabilitation after surgery. Ms Summers spoke to the audience about how exercise is an important complement to any cancer treatment.

"Exercise is medicine," she explained. It can decrease blood pressure, increase energy levels, improve cardiovascular health, promote good sleep, and facilitate weight loss. It can also improve self-esteem and reduce depression.

Studies across cancer types indicate that physical activity is crucial, and can even help improve outcomes. For people who have been diagnosed with cancer, three types of exercise are important: aerobic, resistance, and flexibility. Research reveals that 150 minutes a week of moderate intensity aerobic exercise or 75 minutes a week of vigorous intensity aerobic exercise (or some combination of both), can provide important health benefits. Some people will need to work up to this gradually and everyone should develop an exercise program in line with their individual physical abilities.

Resistance exercise ideally involves muscle strengthening exercises of moderate intensity at least 2 days a week. Flexibility exercise involves stretching major muscle groups on the days that other activities are performed. Pilates focusses on resistance and flexibility. It is a series of exercises that evolved from the idea that the deep abdominal muscles provide stability for the spine.

"These muscles work to support the spine and stabilise the peripheral joints to allow for effective smooth movement that won't result in muscular or skeletal pain," explained Ms Summers. "Those core muscles have to work in a very coordinated way to provide that support and allow us to move so we don't walk around like a robot."

Abdominal surgery can disrupt the abdominal wall and the continuity of the pelvic floor, she said. It changes the dynamics in the core muscles. While newer surgical techniques cause less damage to the core, they can still cause problems with stability, incontinence, and sexual function. Moreover, post-surgical pain can exacerbate this. When we experience abdominal pain our reaction is to lean forward and protect the core, this changes the arrangement of those core muscles. It can also change the way we breathe, shifting our breathing pattern up toward the shoulders, making the breath less efficient and causing shoulder pain.

Pilates teaches you how to contract the muscles for optimal stability and how to maintain the contraction as you move. These exercises can be introduced prior to surgery to strengthen the core muscles. After surgery, it’s important to always consult your doctor before beginning any exercise program. In some cases, particularly after prostate cancer surgery, Pilates can begin fairly soon afterwards.

Pilates' benefits are not limited to post-surgical recovery. There are also benefits to practicing Pilates during chemotherapy, as it can prevent the loss of muscle strength and flexibility, and can even help to stabilise weight. It can also help to maintain cardiovascular fitness and reduce fatigue. Last, but not least, it can increase self-esteem. It's often possible to get in 2 or 3 Pilates sessions between chemotherapy sessions, said Ms Summers.

"We look to keep you strong but not tire you out; give you energy but not take it away."

Research shows that Pilates is also beneficial during hormone therapy and can help off-set some of the side effects. Whatever the circumstance, Ms Summers recommends beginning a Pilates program with a physiotherapist, who can guide you through the techniques. The cost of a small number of sessions may be covered in-part by Medicare with a GP referral. Once you become comfortable with Pilates and have developed a program that suits your individual needs, you can do a lot of the exercises at home. As such it can continue to be an important part of both of your treatment and recovery.